The resident, identified as Resident #1, entered the facility on August 20, 2025, with closed scar tissue on the sacrum and no open wounds. By September 18 — less than a month later — staff documented a stage 4 pressure ulcer at the same location.
During a federal inspection in October, the nursing supervisor acknowledged multiple failures in the resident's care. She admitted writing three late entries in nursing progress notes because "I was not doing my weekly skin notes." When asked why she wasn't performing the required assessments, she responded: "I do not know."
The supervisor initially documented the resident's admission skin assessment as affecting the "buttocks" but later corrected it to "sacrum." She performed the skin assessment on August 20 but didn't see the resident again until September 2 — nearly two weeks later — and only after another nurse called to report the sacral area was "starting to break down."
Despite identifying the resident as having risk for pressure ulcer development, the supervisor failed to provide immediate preventive care. She didn't order an air mattress and positioning wedges until September 9, approximately three weeks after admission, explaining she ordered them because "the resident was not thriving."
The resident's condition deteriorated rapidly. According to the wound care licensed practical nurse, the resident developed sacral excoriation on September 9, progressed to stage 1 within the same week, and reached stage 4 by September 18.
The supervisor attempted to justify the rapid progression, stating that according to a wound physician, "no amount of intervention can prevent the occurrence of Stage 4 pressure ulcer, a few weeks after admission to the facility." However, she admitted she "did not intervene immediately at admission" despite the resident's documented risk factors.
The resident exhibited multiple concerning behaviors during the stay. Staff described the resident as "refusing to eat, drink, refusing clean up, and frequently with closed mouth." The supervisor attributed the wound's rapid deterioration to the resident's "generalized decline."
Standard nursing protocols call for immediate preventive measures for at-risk residents. The supervisor explained that upon admission, residents at risk for skin breakdown should receive "necessary supplies to prevent the development of pressure ulcer" and weekly skin checks where nurses "observe the body for any new areas forming."
She acknowledged that pressure ulcers typically progress through visible stages — "redness, excoriation, deteriorating, then stage 1" — rather than jumping directly to stage 4. She stated she had never witnessed a resident without skin openings on admission develop a stage 4 pressure ulcer within a month.
When pressed about her assessment practices, the supervisor revealed significant gaps in documentation. She wrote the admission skin assessment on August 20 but made no subsequent entries until after being alerted to the resident's deteriorating condition nearly two weeks later.
A licensed practical nurse interviewed during the inspection demonstrated similarly concerning knowledge gaps. When asked about Resident #1's pressure ulcer, she stated she "did not remember" but recalled the resident "was refusing care frequently." She couldn't remember when the care refusals began.
The LPN described following facility policy for pressure ulcer prevention, including barrier cream application, washing and drying the sacral area, frequent incontinence changes, and directing certified nursing assistants to turn and reposition residents. However, when asked if she monitored whether CNAs actually performed turning and repositioning tasks, she responded: "Sometimes."
The facility's own policies require weekly skin assessments to identify developing problems early. The supervisor's admission that she wasn't performing these assessments represents a fundamental breakdown in basic nursing care protocols designed to prevent exactly this type of rapid deterioration.
Stage 4 pressure ulcers represent the most severe category of bedsores, involving full-thickness tissue loss that can extend to muscle, bone, or supporting structures. They typically require specialized wound care and can lead to serious complications including infection and prolonged healing times.
The inspection found the facility failed to ensure residents at risk for pressure ulcers received appropriate preventive care and monitoring. The case illustrates how gaps in basic nursing assessments can lead to rapid deterioration of vulnerable residents' conditions within weeks of admission.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Broward Oaks Nursing and Rehabilitation from 2025-10-08 including all violations, facility responses, and corrective action plans.
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